Provider Demographics
NPI:1457699431
Name:SONG, YOUNG DO
Entity type:Individual
Prefix:
First Name:YOUNG DO
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5134
Mailing Address - Country:US
Mailing Address - Phone:916-784-4050
Mailing Address - Fax:
Practice Address - Street 1:333 BUDLONG RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6337
Practice Address - Country:US
Practice Address - Phone:401-943-4530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIMD14324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program